©Author(s) (or their employer(s)) 2026. No commercial re-use. See Permissions. Published by Baishideng Publishing Group Inc.
Use of radiograph scoring systems to assess pulmonary disease severity in patients with COVID-19 pneumonia
Hayder Mohammed, Khalid Y Fadul, Syed G A Naqvi, Nadir Kharma, Alhady Alfian Yusof, Shabbir Ahmad, Munawar Farooq, Sasha Javid, Ahmed Mohamed, Manar E Abdel-Rahman, Tim Harris
Hayder Mohammed, Khalid Y Fadul, Alhady Alfian Yusof, Shabbir Ahmad, Munawar Farooq, Sasha Javid, Department of Emergency Medicine, Hamad Medical Corporation, Qatar 3050, Qatar
Hayder Mohammed, Department of Emergency Medicine, Leeds Teaching Hospital NHS Trust, Leeds LS9 7TF, United Kingdom
Syed G A Naqvi, Department of Radiology, Hamad Medical Corporation, Qatar 3050, Qatar
Nadir Kharma, Department of Intensive Care Medicine, Hamad Medical Corporation, Qatar 3050, Qatar
Munawar Farooq, Department of Internal Medicine, Emergency Medicine Section, College of Medicine and Health Sciences, Al Ain 15551, United Arab Emirates
Ahmed Mohamed, Department of Orthopaedics, Burjeel Medical City, Abu Dhabi 92510, United Arab Emirates
Manar E Abdel-Rahman, Department of Public Health, Professor of Biostatistics, Qatar University, Qatar 2713, Qatar
Tim Harris, Department of Emergency Medicine, Queen Mary University of London, London E1 4NS, United Kingdom
Author contributions: Mohammed H, Fadul KY, Naqvi SGA, Kharma N, Alfian Yusof A, Ahmad S, Farooq M, and Javid S contributed to the study conception, data collection; Mohammed H, Fadul KY, Naqvi SGA, Kharma N, Alfian Yusof A, Ahmad S, Farooq M, Javid S, and Abdel-Rahman ME contributed to data interpretation; Mohamed A contributed to drafting, organizing, and writing the Discussion section; Abdel-Rahman ME performed the statistical analysis; Harris T provided supervision, critical revision, and oversight of the study. All authors reviewed and approved the final version of the manuscript.
Supported by Hamad General Hospital, Qatar, No. MRC-05-233.
Institutional review board statement: This study was approved by the Institutional Medical Research Council at HMC, Qatar (No. MRC-05-233).
Informed consent statement: Our Institutional Review Board waived the requirement for signed informed consent, as the study involved a retrospective chart review and all patient data were de-identified during collection.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement:
The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Corresponding author: Ahmed Mohamed, Department of Orthopaedics, Burjeel Medical City, 28th Street, Abu Dhabi 92510, United Arab Emirates.
ahmedtom11@hotmail.com
Received: September 8, 2025
Revised: October 8, 2025
Accepted: January 7, 2026
Published online: March 9, 2026
Processing time: 175 Days and 18.9 Hours
BACKGROUND
Severe acute respiratory syndrome coronavirus 2 causes pneumonia in most hospitalized patients, often leading to hypoxemia and the need for supplemental oxygen. While chest computed tomography is highly sensitive, chest radiographs (CXR) offer a practical alternative in high-volume settings. Scoring systems like Radiographic Assessment of Lung Edema (RALE) and BRIXIA standardize CXR interpretation and quantify severity, but their relationship with oxygen delivery requirements in coronavirus disease 2019 (COVID-19) patients remains unclear.
AIM
To evaluate whether the initial emergency department (ED) radiograph could predict subsequent oxygen support requirements. The secondary aim was to assess inter- and intra-rater agreement of the scoring systems.
METHODS
This retrospective cohort study examined consecutive COVID-19 patients presenting to a large tertiary hospital ED (May-June 2020) who required admission and underwent CXR within 24 hours of arrival. Infiltrate severity on ED radiographs was scored using the BRIXIA and RALE systems. Oxygen support was categorized by delivery device, and associations were examined using logistic regression.
RESULTS
Data was analyzed from 950 COVID-19 patients (90.6% male, mean age: 48.4 ± 12.3 years). Predictive performance showed notable variation: At ED admission, both BRIXIA and RALE scores had the highest discriminatory ability [area under the curve (AUC) = 0.74; 95% confidence interval (CI): 0.69-0.79] for predicting oxygen delivery via high flow nasal cannula/continuous positive airway pressure/Bi-level positive airway pressure. Prediction for non-rebreather mask yielded lower AUCs (BRIXIA: 0.65; RALE: 0.62), with nasal cannula use showing limited discrimination (BRIXIA: 0.56; RALE: 0.54). During hospitalization, predictive performance remained modest across all modalities. The AUCs for intubation were 0.63 (BRIXIA) and 0.62 (RALE), while for high flow nasal cannula/continuous positive airway pressure/Bi-level positive airway pressure, values dropped slightly to 0.62 and 0.59, respectively. Non-rebreather mask prediction maintained an AUC of 0.62 for both scores, and nasal cannula predictions remained low (BRIXIA: 0.56; RALE: 0.52). Inter- and intra-rater agreement was excellent in both scores, with inter-rater agreement at 95% (95%CI: 0.94-0.96) and intra-rater agreement at 97% (95%CI: 0.96-0.98) for BRIXIA and 98% (95%CI: 97-98) for RALE.
CONCLUSION
Both RALE and BRIXIA scores effectively predicted the need for advanced respiratory support in ED COVID-19 patients and demonstrated excellent inter-rater and intra-rater reliability. While their predictive power diminished during hospitalization, both scores remain valuable for initial triage, with BRIXIA particularly useful for ruling out the need for high-level oxygen support.
Core Tip: Radiographic Assessment of Lung Edema and BRIXIA chest X-ray scoring systems are effective in predicting the need for advanced respiratory support in coronavirus disease 2019 patients presenting to the emergency department. Both methods show strong prognostic value for identifying patients who require advanced oxygen delivery devices in the emergency department and during their hospital stay. In addition, the two scoring systems demonstrated excellent inter- and intra-rater reliability among emergency medicine physicians, intensivists, and radiologists. Given their comparable performance in clinical practice, the choice between the Radiographic Assessment of Lung Edema and the BRIXIA scores can be determined by institutional preference.
